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091/24/2014 10:36 2093344684 #6346 P.001 /003 <br /> I It <br /> SAN JOAQUIN COUNTY <br /> RECWZ_ <br /> ENVIRONMENTAL HEALTH DEPARTMENT \,00 <br /> 1868 East Hazelton Avenue,Stockton,California 79520i 2322 <br /> hone. (209)468-3420 Fax. (209)468-3433 Web:WV,?W- OvMcgehg <br /> ED 1 <br /> KL 'M Am I <br /> SEP 2 4 2014 <br /> RE,rURN TO COMPLIANCE CERTIF!I".'F'ATIO) <br /> N <br /> ENVIR L,HEALTF <br /> tions n)ted in the"Notice to Comply"in the attached Inspection Report must be <br /> W�Tkliqlrn 30 daof receipt of this inspection. This certification form must be submitted to the <br /> Environmental Health D-1partment(EH0)address at the top of this form within 30 days of receipt of the <br /> inspection Report. HSG 25404.1.2(c)(1) <br /> All corrections to they violations noted in the attached Inspection Report(1 )or Continuation Form,or <br /> disputes to any violatiors, are to be submitted using this certification and returned to EHD within 30 daLs <br /> unless otherwise specffi ad in the Inspection Report. HSC 25185(c)(3) <br /> Note: All EHD staff t me associated with failing to comply by the above noted dates will be <br /> billed at the vt irrent hourly rate. <br /> For this certification to be complete the operator of tha site must include: <br /> • A statement documenting what corrective actions were taken or will be taken for each violation <br /> • Copies of sample results/rhanifests/training records/other appropriate paperwork, and/or photos <br /> verifying corrections <br /> • Operator's certification <br /> Inspection Date: Inspected By:,Aris Cacapit <br /> Facility Address:4 EPA 113#ja_„ D <br /> I certify under penalty of law that: <br /> 1. 1 have corrected the violations specified in the Inspection Report from the above-mentioned <br /> inspection date. <br /> 2, 1 have personally examined the following documentation su/bmitt pliance FOR <br /> s p <br /> EACH VIOLATION and I believe the information be true,ac rate, and complete, <br /> Photos <br /> Paperwork Statement <br /> 3. 1 am authorized to submit this certification on behalf of the Respond nt, <br /> 4. 1 am aware that there are significant penalties for submitting false in rormation, including the <br /> possi ie and/or imprison t for known violations- (HSC 25191) <br /> Name- > jv�" le:_ <br /> Signature__ ,.. Ace� Date: <br /> EHD 22-02-005 Rev 0411SM2 <br />